§500.APPENDIX C. Marriage Application and Record

STATE OF ILLINOIS

STATE FILE NUMBER

MARRIAGE APPLICATION AND RECORD

TYPE / PRINT IN PERMANENT BLACK INK

County

License Number

1. Groom –  Name

First

Middle

Last

2a. Residence – Street and Number or R.F.D.

2b. City

2c. County

2d. State

GROOM

3a. Date of Birth (Month, Day, Year)

3b. Age

3c.    Birthplace (State or          Foreign Country)

4. Social Security Number

5. Usual Occupation

Printed by the Authority of the State of Illinois

6a. Father – Name

6b. Address

6c. Birthplace (State or       Foreign Country)

7a. Mother – Maiden Name

7b. Address

7c. Birthplace (State or       Foreign Country)

8a. Bride  –  Name

First

Middle

Last

8b. Maiden Name (If Different)

9a. Residence – Street and Number or R.F.D.

9b. City

9c. County

9d. State

BRIDE

10a. Date of Birth (Month, Day, Year)

10b. Age

10c.  Birthplace (State or          Foreign Country)

11. Social Security Number

12. Usual Occupation

13a. Father – Name

13b. Address

13c.  Birthplace (State or          Foreign Country

14a. Mother – Maiden Name

14b. Address

14c.  Birthplace (State or          Foreign Country

15. If Parties Are Related To Each Other – Specify Relationship

16. This License Effective On –

WE HEREBY CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE TO THE BEST OF OUR KNOWLEDGE, THAT WE ARE FREE TO INTERMARRY UNDER THE LAWS OF THIS STATE AND THE LAWS OF THE JURISDICTION WHERE WE RESIDE AND WE ARE THE IDENTICAL PERSONS NAMED IN THE ACCOMPANYING PHYSICIAN'S CERTIFICATES.

AFFIDAVIT

17. Groom (Sign Full Name) ►

18. Bride (Sign Full Name) ►

19. Subscribed and Sworn To Before Me On:

20. Signature of County Clerk

By

Deputy

21. Date of Marriage (Month, Day, Year)

22. Place of Marriage (City, Vill., or Town. If Rural, Give Twp. Name or Road Dist.)

23. Type of Ceremony       (Religious or Civil)  (Specify)

MARRIAGE RECORD

24. Name of Officiant

25. Title

26. Date Recorded (Month, Day, Year)

27. Signature of County Clerk

By

Deputy

VR 600 (1989)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH – OFFICE OF VITAL RECORDS

(BASED ON 1989 U.S. STANDARD FORM)

INFORMATION FOR STATISTICAL PURPOSES ONLY

Race

Education (Specify Highest Grade Completed)

Number of This Marriage

If Previously Married – Last Marriage Ended by Death, Dissolution or Invalidity of Marriage

SPECIFY (e.g. WHITE, BLACK, AMERICAN INDIAN, ETC.)

ELEMENTARY OR SECONDARY (0-12)

COLLEGE (1-4 OR 5 +)

FIRST-SECOND ETC. (SPECIFY)

SPECIFY HOW

SPECIFY WHEN (MONTH, DAY, YEAR)

SPECIFY WHERE-COUNTY & STATE

GROOM

28.

29.

30a.

30b.

30c.

30d.

BRIDE

31.

32.

33a.

33b.

33c.

33d.

34.      Of Hispanic Origin?

34a.

□  No

□  Yes

34b.

□  No

□  Yes

(Specify No or Yes – If yes, specify

GROOM

BRIDE

Cuban, Mexican, Puerto Rican, etc.)

Specify:

Specify:

IL 482-0010

 

 

AFFIDAVIT OF CONSENT OF PARENT OR GUARDIAN FOR MARRIAGE OF MINOR

 

STATE OF ILLINOIS                   SS.

COUNTY______________________

 

_________________________________________________   AND   _________________________________________________

 

BEING DULY SWORN, DEPOSES AND SAYS THAT THEY ARE THE PARENTS OR GUARDIAN OF_______________________,

 

A MINOR, AND GIVE THEIR CONSENT TO THE MARRIAGE OF SAID MINOR TO___________________________________, AND

 

AFFIANTS FURTHER SAY THAT THE SAID MINOR WAS BORN__________________, 19____.

 

 

 

SIGNATURE OF FATHER OR GUARDIAN
SIGNATURE OF MOTHER OR GUARDIAN

 

 

SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ____________________________, 19______.

 

 

 

 

SIGNATURE OF COUNTY CLERK OR NOTARY

 

 

 

 

 

 

STATE OF ILLINOIS                   SS.

COUNTY______________________

 

_________________________________________________ AND __________________________________________________

 

BEING DULY SWORN, DEPOSES AND SAYS THAT THEY ARE THE PARENTS OR GUARDIAN OF_______________________,

 

A MINOR, AND GIVE THEIR CONSENT TO THE MARRIAGE OF SAID MINOR TO_________________________________, AND

 

AFFIANTS FURTHER SAY THAT THE SAID MINOR WAS BORN__________________, 19____.

 

 

 

 

SIGNATURE OF FATHER OR GUARDIAN
SIGNATURE OF MOTHER OR GUARDIAN

 

 

SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ____________________________, 19______.

 

 

 

 

SIGNATURE OF COUNTY CLERK OR NOTARY

 

(Source:  Added at 15 Ill. Reg. 11706, effective August 1, 1991)